Jeffrey S. Dover

The spectrum of laser skin resurfacing: nonablative, fractional, and ablative laser resurfacing.

UNLABELLED The drive to attain cosmetic facial enhancement with minimal risk and rapid recovery has inspired the field of nonsurgical skin rejuvenation. Laser resurfacing was introduced in the 1980s with continuous wave carbon dioxide (CO(2)) lasers; however, because of a high rate of side effects, including scarring, short-pulse, high-peak power, and rapidly scanned, focused-beam CO(2) lasers and normal-mode erbium-doped yttrium aluminium garnet lasers were developed, which remove skin in a precisely controlled manner. The prolonged 2-week recovery time and small but significant complication risk prompted the development of non-ablative and, more recently, fractional resurfacing in order to minimize risk and shorten recovery times. Nonablative resurfacing produces dermal thermal injury to improve rhytides and photodamage while preserving the epidermis. Fractional resurfacing thermally ablates microscopic columns of epidermal and dermal tissue in regularly spaced arrays over a fraction of the skin surface. This intermediate approach increases efficacy as compared to nonablative resurfacing, but with faster recovery as compared to ablative resurfacing. Neither nonablative nor fractional resurfacing produces results comparable to ablative laser skin resurfacing, but both have become much more popular than the latter because the risks of treatment are limited in the face of acceptable improvement. LEARNING OBJECTIVES At the completion of this learning activity, participants should be familiar with the spectrum of lasers and light technologies available for skin resurfacing, published studies of safety and efficacy, indications, methodologies, side effects, complications, and management.

New approaches to the treatment of vascular lesions.

The pulsed dye laser was developed based on the concept of selective photothermolysis. By using a wavelength of light well absorbed by the target and pulse duration short enough to spatially confine thermal injury, specific vascular injury could be produced.

Delayed pressure urticaria: Clinical features, laboratory investigations, and response to therapy of 44 patients

We studied 44 patients with delayed pressure urticaria. The mean age at onset of the disease was 33 years (range, 5 to 63 years) and the mean duration of disease was 9 years (range, 1 to 40 years). After pressure stimulus, the mean onset of whealing occurred in 3 1/2 hours, the mean peak swelling occurred after 10 hours, and the mean lesion duration was 36 hours. Two thirds of patients had generalized flulike symptoms. Sixty percent had disabling nonremitting delayed pressure urticaria. Sixty-two percent had coexistent chronic idiopathic urticaria, and 27% had angioedema. Delayed pressure urticaria was confirmed by pressure tests with either a calibrated dermographometer or suspended weights. More than 50% of patients tested also had delayed dermographism. A double-blind, controlled, crossover trial of indomethacin therapy in 14 patients revealed no significant subjective improvement or reduction in area of induced wheals. We conclude: (1) The diagnosis of delayed pressure urticaria can be easily made by dermographometer testing. (2) Delayed dermographism may be the same entity as delayed pressure urticaria induced by a different method of pressure application. (3) Systemic corticosteroids remain the only known effective treatment for disabling delayed pressure urticaria.

Cutaneous effects and therapeutic uses of heat with emphasis on infrared radiation

The adverse effects and therapeutic benefits of heat, specifically infrared radiation, on skin have received little attention. In this review we discuss the evidence indicating that heat and infrared radiation are not totally harmless, but that they may be involved in both photoaging and photocarcinogenesis. We also review the clinical syndrome thought to be caused by infrared radiation and the therapeutic uses of both local heat and infrared radiation.

A clinical and histologic prospective controlled comparative study of the picosecond titanium : Sapphire(795 nm)laser versus the Q-switched alexandrite(752 nm)laser for removing tattoo pigment

BACKGROUND Theory predicts that picosecond lasers should be more effective than the currently available nanosecond lasers in removing tattoo ink. In addition to thermal confinement, such pulse widths cause optimal photomechanical disruption of the target. OBJECTIVE This study compared the efficacy of the picosecond titanium:sapphire (795 nm, 500 psec) laser and the Q-switched alexandrite (752 nm, 50 nsec) laser in the treatment of tattooed guinea pigs. METHODS Six albino guinea pigs, each with 6 uniformly 1 cm circular black tattoos, were treated. Three of the tattoos were divided into 2; one half was treated with the titanium:sapphire laser and the other half with the alexandrite laser. Fluences used for both lasers were 6.11, 4.24, and 2.39 J/cm2 with spot sizes of 1.25, 1.5, and 2 mm, respectively. The remaining spots served as control. Clinical evaluation and biopsies were performed at baseline and at 11 and 16 weeks after a single laser treatment. RESULTS Greater clearance of tattoo was observed in titanium:sapphire laser-treated areas in 2 of the 4 surviving guinea pigs. In some areas total clearing was observed after the single titanium:sapphire laser treatment. Clearing improved with higher fluences. No scarring was present. Histologic results showed similar findings. CONCLUSION Our findings suggest that the picosecond titanium:sapphire laser is more effective than the Q-switched alexandrite laser in removing tattoo pigment and may be of significant clinical utility.

A clinical overview of hair removal using lasers and light sources

The tremendous demand for removal of unwanted hair has led to the development of a wide range of noninvasive, user-friendly laser and light source systems; however, despite considerable advances in this field, these devices still have the potential to cause injury when used improperly. It is important to follow precise treatment guidelines in order to attain optimal results. This article gives an overview of the currently available lasers and light sources. It focuses on the practical aspect of laser hair removal by discussing patient selection, safety precautions, techniques using the different systems, pre- and post-laser treatment care, proper treatment endpoints, expected outcome, and possible side-effects and complications.

Management of complications and sequelae with temporary injectable fillers.

Background: Injectable nonpermanent soft-tissue augmentation materials are extremely well-tolerated products that can be used safely in virtually all patients who are candidates for facial augmentation. In this article, the authors review the management of the few common and minor undesirable effects that may be associated with temporary fillers; in addition, the authors mention the rare incidence of serious complications. Methods: The authors conducted a MEDLINE-based (1990 to 2005) review of complications and side effects of nonpermanent injectable filler materials. This review was supplemented with evidence presented at recent plastic surgery and dermatology scientific meetings and unpublished information made available to the authors. Results: Nonpermanent injectable soft-tissue augmentation materials are extremely safe substances that are unlikely to cause more than mild injection discomfort, transient redness and swelling, and occasional short-term bruising when used for facial augmentation. Symmetry can usually be maintained with judicious bilateral use of injectant, and injection-site necrosis is rare and treatable. Proper technique minimizes the already very low risk of visible implants, nodule formation, and hypersensitivity reactions. Other serious effects are exceedingly rare, and retinal artery thrombosis, previously associated with injectable collagen, has not been seen with newer fillers. Conclusions: Injectable nonpermanent fillers are extremely safe substances. Attention to injection technique further minimizes the low risk of adverse events, which are usually minor, spontaneously resolving, and easily treated.

Blinded, Randomized, Quantitative Grading Comparison of Minimally Invasive, Fractional Radiofrequency and Surgical Face-lift to Treat Skin Laxity

OBJECTIVES To quantify the improvements in laxity from the surgical face-lift and to perform a randomized, blinded comparison with the clinical effects of a novel, minimally invasive fractional radiofrequency (FRF) system. STUDY DESIGN Randomized, blinded, comparative trial. PATIENTS Fifteen sequential patients with facial skin laxity enrolled in the trial and completed FRF treatment and follow-up. Baseline and follow-up digital photographs of patients undergoing FRF were randomly mixed with 6 sets of baseline and follow-up images of patients undergoing surgical face-lift with equivalent baseline facial laxity grades. MAIN OUTCOME MEASURES Five independent blinded evaluators graded randomized baseline and 3- to 6-month follow-up photographs using a comprehensive quantitative 4-point laxity grading scale. Quantitative changes in laxity grades were calculated and compared statistically for FRF treatment vs surgical face-lifts. Patient satisfaction and adverse events were also evaluated. RESULTS Blinded grading of unmarked, randomized baseline and follow-up photographs of patients undergoing FRF treatment randomized with baseline and follow-up photographs of patients undergoing surgical face-lift demonstrated statistically significant improvement in facial laxity, with a mean grade improvement of 1.20 for patients in the surgical face-lift group and of 0.44 for FRF-treated patients on a 4-point laxity grading scale (P < .001). The improvements relative to baseline were 16% for FRF treatment compared with 49% for the surgical face-lift. The mean laxity improvement from a single FRF treatment was 37% that of the surgical face-lift. Patient satisfaction was high (dissatisfied, 0%; neutral, 7%; satisfied, 60%; and very satisfied, 33%). All participants in the FRF treatment group experienced transient erythema, mild edema, and mild to moderate purpura that resolved in 5 to 10 days, and they returned to normal activities within 24 hours. There were no adverse events or complications in the FRF group. All patients in the surgical face-lift group experienced scarring at surgical margins, erythema, edema, and ecchymosis, and they returned to normal activities on suture removal at 7 to 10 days. CONCLUSIONS This randomized, blinded, quantitative assessment using a validated grading scale of skin laxity improvement from the gold standard treatment, the surgical face-lift, and comparative analysis to a novel, minimally invasive FRF treatment has demonstrated 49% improvement in skin laxity relative to baseline for the surgical face-lift, compared with 16% for FRF. The surgical face-lift resulted in a mean 1.20-grade improvement on the 4-point laxity grading scale. In comparison, a single, minimally invasive FRF treatment demonstrated a 0.44-laxity grade improvement, or 37% that of the surgical face-lift, without the adverse effects and complications of surgical procedures. This study provides a basis for quantifying cosmetic outcomes from novel treatments with comparative analysis to the gold standard. It also suggests that minimally invasive FRF treatment may provide an important nonsurgical option for the treatment of facial skin laxity.

Cutaneous laser surgery

Abstract More than 30 years of experience have resulted in advances of the technology, technique, and therapeutic efficacy of dermatologic lasers. The original lasers have been modified and improved, and new lasers with a more sophisticated technology have been introduced. Laser therapy has provided novel ways of treating difficult conditions and, for several skin diseases, it is now considered the treatment of choice. The goal of this article is to review laser physics and laser-tissue interactions, discuss the various groups of lasers and their clinical uses in dermatology, and to contemplate future developments in laser skin surgery.

BASIC LASER PRINCIPLES

Skin diseases have been treated with lasers since the early 1960s. The three principal chromophores in the skin--hemoglobin, melanin, and water--have different absorption spectra that selectively absorb certain wavelengths of electromagnetic radiation. A given wavelength and pulse duration will selectively treat a target containing a chromophore. The wide variety of lasers and their applications are discussed.